the bilateral mandible.
2. Compression of salivary outflow.
POSTOPERATIVE DIAGNOSES: 1. Significantly enlarged torus mandibularis of
the bilateral mandible.
2. Compression salivary outflow.
3. Significant floor of mouth edema
postoperatively.
PROCEDURES PERFORMED: 1. Submucous resection of osseous, benign oral
cavity lesion, greater than 5 cm bilaterally.
2. Placement of bolster on the left.
.
COMPLICATIONS: The surgery went as planned submucous
resection of the osseous lesions was conducted. Unfortunately after the conclusion of the case, the
patient was noted to have significant postoperative swelling of floor of mouth, such that it was felt unsafe
to extubate the nasotracheal tube. The decision was made to do a direct doctor to doctor transfer to the
surgical ICU at St. Joseph’s Hospital and Medical Center. This was performed and the patient was taken
under the care of Dr. Wright and his team. The plan will be to have the patient monitored, diuresed and
treated with high-dose steroids to get the swelling to subside prior to control the extubation. This would be
anticipated to occur within the next 24 to 48 hours. The plan of care was addressed with the patient’s
family and their consent was given to proceed forward. I was participatory and present for this entire
process.
INDICATION FOR PROCEDURE: Janet is a pleasant 80-year-old white female with history of
extremely large torus mandibulari of the bilateral mandible. These have grown to an extent that they are
causing compression on the floor of the mouth structures and salivary outflow tracts and also becoming
extremely uncomfortable to her. Her voice is changing. Her airway has been stable. After discussing
various options and obtaining CT imaging, the decision was made in conjunction with the patient’s wishes
to proceed forward with the surgical debulking via transoral submucous route. The risks of the procedure
discussed did include bleeding, floor of the mouth hematoma, infection, damage to the salivary ducts or
glands, damage to the lingual nerve, taste change, difficulty moving the tongue, change in the ability to
swallow, aspiration, pneumonia, swelling, airway compromise. Understanding these risks, Janet did wish
to proceed forward.
DESCRIPTION OF PROCEDURE: The patient was identified in the holding area. All consents and
paper work were up-to-date and complete. She was wheeled to the operative suite in stable condition. A
nasotracheal intubation was conducted without incident. The head of bed was rotated 90 degrees. A full
time-out was taken. The oral cavity was exposed using a Smiley mouthgag. A single silk stitch was
placed through the midline at the tip of the tongue in the raphe and secured to pull the tongue out of the
way of the surgery and prevent trauma from drilling. Starting on the right and then proceeding to the left,
mucosal incisions were made with a Colorado needle tip Bovie taking care to preserve this mucosa to the
greatest extent possible. Mucosa flaps were elevated, exposing the extremely large tori bilaterally. It
turned out that these were actually multifocal lesions. There was two on the right and three on the left.
The posterior most lesions were extremely large. At this point, the microscope was brought into the field
and using various cutting and diamond burs, the tori were dissected from an inside out fashion. The tori on
the right especially had developed a form of soft tissue. I suspect this was a narrowest space. As the
soft tissue was taken, biopsied and sent across the street to the histopathology lab at St Joseph Hospital
and Medical Center. Hemostasis was excellent. The entirety of the tori visible was removed. Great care
was taken not to violate the dental roots or the overlying mucosa. When the tori were removed, the
mucosa was re-approximated with simple interrupted stitches in a semi-watertight fashion. Decision to
place a bolster was made. This was done on the left side, secured with silk stitches, sutured around the
mandibular molars. At this point in the case, we were preparing to wrap up and extubate the patient on
one final inspection and with plans to suction the oropharynx and esophagus, it was noted that the patient
had significant floor of mouth edema that had erupted after removal of these tori. We thought by myself,
the attending surgeon that the chronic compression of the tori on the soft tissues of the floor of mouth had
allowed for fresh third spacing edema phenomenon to occur once they were removed. This was
exaggerated enough that given the patient’s advanced age and history of atrial fibrillation, we did not want
to take a chance of potentially losing an airway. The decision was made at this point by myself and in
conjunction after full discussion and disclosure with the family to transfer across the street at St. Joseph’s
Hospital and Medical Center via ambulance to the surgical ICU. A doctor to doctor conversation was
conducted between myself and Dr. Wright, who was the accepting physician. Plan of care will be to have
Janet diuresed, treated with high-dose steroids and H2 blockers to see if we can get this edema to subside
in lieu of a planned and controlled extubation. I was scrubbed and participatory and present for this entire
process and the procedure.